Page 43 - District 20-K1 Kings & Queens E-Newsletter December 2021

MD-20 ORGANIZATION OF PAST DISTRICT GOVERNORS
Leadership Achievement Award Nomination Form
Lion Nominee _____________________________________________________________________________________
Address ___________________________________________________________________________________________
City _____________________________ State _____________________ Zip Code_______________________________
Phone________________________________ Email _______________________________________________________
Club_________________________________________ District ______________________________________________
Length of Membership_______________________________________________________________________________
Person making this Nomination ________________________________________________________________________
Club Name _________________________________ Club Number_____________________ Phone _________________
Please supply as much information as possible to aid in the selection of this year’s recipient.
Club involvement (include offices, chairmanships, and dates):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Zone and District involvement (include dates):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Awards received (Membership, Extension, Lion of the Year, etc.):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Why is this nominee deserving of this Leadership Achievement Award?
___________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Nominee’s Personal Information:
Spouse / Partner in Service’s Name:_____________________________________
Number of Children: __________ Number of Grandchildren:_____________
Occupation: __________________

The biography and picture of each recipient will be published in the State Convention Program. A digital black and
white photo of the recipient (full face, waist up, in the MD-20 Uniform) must be submitted immediately 22following the
selection of the successful recipient.

ALL NOMINATIONS MUST BE SUBMITTED BY E-MAIL
NO LATER THAN JANUARY 17, 2022
PDG MARIA SIERRA
E-MAIL: LIONMARIASIERRA@AOL.COM - TEL: 212-781-0074